Victoria House

Contract Monitoring Report

  • Name/Address of Provider: (My Choice Healthcare) Victoria House, Gordon Road, Blackwood, Caerphilly, NP12 1DS
  • Date of Visit: Tuesday 20th February 2024
  • Visiting Officer(s): Amelia Tyler: Contract monitoring officer
  • Present: Claire Stanton: Registered Manager, Nicola Mullins: Operations Manager


Victoria House is a residential home for people with a learning disability located in Blackwood with easy access to all the local amenities. The property is owned and run by My Choice Healthcare, who are a registered provider within Caerphilly borough.

The property is a large, detached dormer bungalow and at the time of the visit there were three residents: one funded by CCBC, and two funded by a neighbouring local authority. The building had three bedrooms and an office and therefore had no vacancies at the time of the visit.

The home was inspected by The Care Inspectorate Wales on the same day through an unannounced visit. The purpose of the visit was to speak to the manager, staff, and tenants and to look at the documentation.

The previous visit to the home by the contract monitoring officer was conducted on the 7th September 2022, and at this time there were three corrective and one developmental action identified; these actions were reviewed, and the findings are outlined in the section below.

Dependant on the findings within the report, corrective and developmental actions will be given to the provider to complete. Corrective actions are those which must be completed (as governed by legislation), and developmental actions are good practice recommendations.

Previous Recommendations

Poor quality of photograph on staff members file to be updated. RISCA version 2 (April 2019) schedule 1, regulation 35, part 1 (1). Met. Two staff files were seen as part of the visit, and it was acknowledged that both contained good quality, recent photos.

Training to be sourced around dementia care and for communication. RISCA version 2 (April 2019) regulation 36. Partially met. Communication and dementia training was not evidenced on the training matrix provided. The Manager explained that dementia training had been provided by the local health board in May 2023 and this was to be accurately reflected on the matrix. The eLearning training around communication was sent out to the staff team during the visit and this will be updated on the matrix once completed.

Personal plans to incorporate more person-centred detail such as preferences, dislikes, independent tasks, and outcomes. Additional information to be incorporated around what the person can do independently and focus on any agreed goals. RISCA version 2 (April 2019) regulations 14 and 15. Met. The personal plans were detailed, and person centred and were written in the first person format, which makes them easier to read and maintains focus on the individual. The contract monitoring officer commented that they focussed on the skills and abilities of the person before documenting what their support needs are and how these are to be met.

The manager to contemplate booking relevant staff onto the International Certification of Digital Literacy. Not met. The manager explained that this was something they still intended to complete, but due to external pressures outside of work, this hadn’t been possible. It was explained they still intend to complete a course with the local library over the next twelve months to assist with the demands of the post.

Findings from Visit

Desktop audit

No concerns had been raised by the assessment care management team and there were no enforcement notices for the property at the time the visit was carried out. Since the previous meeting, there had been one safeguarding concern raised by a health professional, and this was shared with the safeguarding team and was acted upon by the provider promptly with appropriate measures being taken.

The training matrix was provided prior to the visit and as previously mentioned there were some gaps in the mandatory training; the manager was in the process of addressing these voids. The matrix is looked at in greater detail within this report.

A copy of the supervision and appraisal matrix for 2023 and 2024 were also shared and it was evidenced that staff were receiving appropriate supervisions more frequently than required; all staff must attend a supervision session at least every three months, and it was acknowledged that the majority are completing this every other month. There was only one exception noted where a staff member had a four month gap without any explanation recorded on the document.

It was noted that the start dates for all staff were recorded on the document which assists in determining when their annual appraisal is due; approx. twelve months on from the commencement of employment. All staff had evidence of an appraisal in 2023 and planned dates for 2024. There was only one member of staff that had not had an appraisal as they had only started in December 2023.

The only recommendation that was made around the supervision and appraisal matrix was for full names to be recorded to ensure accuracy and transparency and remove any possibility of confusion.

The home manager shared a copy of the Resident’s guide, and it was noted this was dated February 2024 and was up to date. The document did not stipulate when the next review is required, but it was explained this would be amended as and when needed. To evidence the document is compliant with legislation, it is recommended it states that it will be reviewed at least annually. It was noted that the manager is registered with Social Care Wales.

The contract monitoring officer was told that the client files are stored securely in a lockable cabinet in the activity room and staff files are also held securely in the office.

Responsible individual

It was confirmed that quarterly visits are carried out by the responsible individual and the most recent regulation 73 visit had been carried out on the 27th November 2023. The report evidenced feedback from staff, observations of interaction, and the environment/fabric of the building and an action plan was drawn up. The report mentioned there was a part time vacancy and it was stated this had been filled.

The statement of purpose was seen, and this was dated April 2023 and had been updated with the details of the new manager. It was explained that if the registered manager and responsible individual were both absent for 28 days or more, that The Care Inspectorate Wales would be notified, and the service would be overseen by the operations manager with support from the staff team. It was stated that there aren’t deputy managers in the homes, but the contract monitoring officer was told that a senior staff member was going to be appointed to support the registered manager.

All policies and procedures were in place at the property including safeguarding, infection control, staff discipline, medication, whistleblowing, and finances. It was highlighted that these had all been reviewed in February 2024 except for one and it was stipulated these would next be reviewed in February 2025 unless it was necessary to do this beforehand. The contract monitoring officer noted that the complaints procedure had been dated ahead of time (June 2024) and it was explained these needed to be corrected and the new contact details for the complaints team within Caerphilly to be updated.

File and documentation audit

The file was viewed for the individual that had been supported to move by Caerphilly CBC. There was no pre-admission assessment on file, but it was explained that this had probably been archived. It was documented that they had previously lived in another supported living property for fourteen years.

As previously mentioned, the personal plan was written in first person with their agreed goals. The contract monitoring officer noted there were plans to arrange a special holiday to Disneyland next year to celebrate their 50th birthday. It was recommended that the goal should be included for one gentleman to lose weight due to previous back surgery. This recommendation was made by a health professional to ensure he is free from pain and be able to maximise his mobility, independence, and wellbeing. The goal should document the ideal weight and how often it has been agreed he will be weighed (once discussed with the individual).

There was evidence of involvement from the key worker and home manager in compiling the personal plan and it was also acknowledged that a review of the care and support plan had been undertaken by the social worker in October 2023 which was also incorporated into the personal plan. Although the document hadn’t been signed by the gentleman, it was recorded that he lacked capacity to be able to sign.

An integrated risk assessment on file and a complex risk management plan that had been completed in September 2023 with involvement from their next of kin, manager, social worker. It was noted that reviews were being undertaken at least every three months and these had been conducted on the 7th November 2023, 1st December 2023, and February 2024. This had been re-written with additional information being provided.

Daily recordings were seen from the 15th to the 19th February, and these provided detailed information, however, lacked evidence of community access. The manager stated that the people living at Victoria House are supported for meals out and this isn’t impacted by staffing levels (four out of the 9 members of staff are allocated drivers). On the day of the visit one of the residents was seen walking in the garden and was supported to go out to a coffee morning. Staff must ensure they record where individuals have indicated that they do not wish to go out.

Residents are referred to outside professionals where needed and it was evidenced there had been involvement from a community nurse and another resident was waiting for an appointment with a clinic in Chepstow.

There was a signed agreement in place with the next of kin indicating they would want to be notified verbally of any accidents, incidents, or changes to health. There was no consent from the person being supported as they lacked capacity to be able to consent.

It was documented that none of the residents regularly choose to stay in their rooms, but if the decide to do so they are checked on regularly. The file seen contained a life story, what they enjoy doing and what is important to them, such as going out or meals or having a takeaway. It was also evidenced that one resident enjoys anything to do with animals. All residents can make themselves understood and if they aren’t able to verbalise their wishes, they will take the member of staff and show them what they want or show them pictures.

There was a DNR form (do not resuscitate) in place and it was recorded that this had been discussed with the next of kin on the 13th May 2022. The contract monitoring officer also noted that a current deprivation of liberty was in place that was due to expire on the 3rd September 2024.

Staffing and training

There are nine members of staff in the team, and it was stated that two work from 7am to 2pm, two work between 2pm and 9pm and there is one waking night staff from 9om until 7am the following day.

Staff absences are covered by the in-house team where possible, and if this can’t be accommodated this is rolled out to the other sister homes in the local area. The contract monitoring officer was also told that the operations manager is very hand on and knows the residents well and can cover shifts if needed. Agency staff aren’t used unless essential as they try to maintain consistency.

Training is delivered electronically through a provider called Citation Access. Courses such as safeguarding, and infection control are delivered and followed up with competency tests to determine the level of understanding. Courses such as emergency evacuation, fire awareness, deprivation of liberty and the All Wales Manual Handling Passport are delivered in person.

The quality of training in evaluated by the manager and operations manager when they attend and they are then able to identify any gaps. There are end of course exams, medication competency assessments and evaluation forms that are also used to ensure the training covers all necessary topics. The contract monitoring officer was also informed that training is discussed in team meetings and supervisions.

Members of staff do not regularly work more than 48 hours a week, however, it was explained that they are currently working additional hours on a temporary basis to cover a staff member that is off work.

There was insufficient evidence at the home that the active offer was being implemented; it was explained that there are no Welsh speaking staff or residents at the time of the visit. It was acknowledged that there is a Welsh phrase of the week displayed in the activity room and staff are encouraged to use Welsh phrases. The manager informed the contract monitoring officer that one of the gentlemen also has a book that is written in English and Welsh. It is recommended that the initial assessment asks the question first around what their preferred method of communication, preferred language is.

All mandatory training was documented on the training matrix, including safeguarding, infection control, food hygiene, first aid, and manual handling. Two staff files were seen as part of the monitoring process; one for a newer member of staff and one for a staff member that had worked at Victoria House for nine years. Both files contained two references, job description, detailed application forms, copies of birth certificates, recent photos, DBS checks, and evidence of induction. It was noted that this was the first job for one of the staff, but three were personal references available and there were no unexplained gaps in employment for either employee.

It was noted that both staff had contracts of employment in place, and both had been signed by the registered manager, but only one had been signed and dated by the member of staff. It is good practice to ensure that both parties have signed up to the agreement to evidence that both parties are aware of the agreement. Interview records were seen, and it was noted that one had been completed by one interviewer and the other had two; where possible it is good practice to have two people conducting interviews to ensure fairness in the event that the outcome is challenged.

Only one file contained a copy of the passport, and it is advised that if this isn’t available that a signed and dated file note is held stating the reason.

Supervision and appraisal

As previously highlighted, all members of staff were receiving supervisions at least once every three months and attending an annual appraisal. The manager explained that supervisions and appraisals are a two-way conversation and staff are expected to contribute meaningfully to the discussion. Appraisal sessions also provide the opportunity for the provider to gain feedback and suggestions for improvement and development. It was pleasing to note that the staff member that had been with the provider for nine years had pre-appraisal forms on file to demonstrate their contribution.

Approach to care

During the visit one of the residents wasn’t feeling well so remained in their room. It was acknowledged that they were checked on regularly and had their breakfast taken to their room. It was acknowledged that when they were ready, they requested that the operations manager supported them with their personal care.

All staff that were spoken to were knowledgeable about the preferences and support needs of the people living at the home. The activity room had puzzles, crafts, board games and sensory sand. It was explained that one of the gentlemen responds well to sensory lights and find these calming. The contract monitoring officer noted that there were a lot of these lights present in the activity room. One of the other gentlemen likes books and newspapers and showed one of his books to the contract monitoring officer. It was also mentioned that the other resident enjoys the cinema and musical shows and it supported to do these when possible. There is a weekly activities board using Velcro to highlight what has been agreed. It was emphasised that this is flexible, and activities can be moved around if they haven’t been pre-arranged or pre-paid.

There is a four weekly menu that is decided with as much involvement from the residents as possible and considers known likes and dislikes. The manager stated that staff try to encourage a healthy balanced diet and prepare meals at home where they can and try to minimise the amount of carbonated drinks. Two of the residents enjoy going out to the supermarket to do the food shopping whereas one of the gentlemen can find it overwhelming.

It was explained that only one of the residents can help with food preparation and is encouraged to do so when they wish to do so. There is a food safety book in place at the property which document any allergies or incidents and if there are any changes, they will contact the SALT team and inform family members and necessary professionals.

The only mobility aid at the property is a wheelchair that was self-purchased for longer distances and it was explained that no assessment had been carried out.

Complaints and compliments

In accordance with the complaints policy, any complaints made directly to the provider are investigated and the outcome is provided in writing to the complainant if known. Depending on the nature of the complaint, staff would be informed either directly in person or at a team meeting. To share good practice and lessons learned, these are also discussed at the manager’s meetings. Complaints are reviewed at least every six months as required.

It was stated that no practice had needed to be changed as a result of any complaints, however, the referral that was received was appropriately investigated and addressed and the staff team were reminded of the complaints and whistleblowing policies and their duty of care to those they support.

The home environment

There was no allocated smoking room and it was highlighted that any staff that wish to do so do this away from the property.

One of the residents’ rooms was seen and was noted to be well maintained apart from a curtain pole that had been broken. There was evidence of personalisation though lighting, photos, a foot bath and some new blinds that they had been supported to choose.

All areas of the home that were seen were clean and tidy. It was noted that some of the spindles on the stairs were either missing or wobbly and it was stated that this needed to be addressed. The bathroom on the upper floor was in the process of being redecorated and this was to be completed in the coming weeks.

One of the bedroom doors downstairs had a lock on it but could only be opened with a key; this needs to be replaced so that staff can gain access in an emergency. It was also stated that the residents don’t carry their own set of keys and risk assessments must be implemented to outline the rationale for this.

Staff questions

One of the staff members were spoken to during the visit and they explained they knew where all relevant documentation was stored. When asked, they said the home manager spends time walking around the home and engage with staff and residents and offers guidance where needed.

It was highlighted that the amount of time spent out in the community, and this can be dependent on the weather. The contract monitoring officer was told that one of the residents can occasionally be reluctant to go out, but this didn’t impact on the other residents.

The staff member demonstrated a good understanding of the needs, preferences and routines of the residents and it was mentioned that one resident can be disinclined to get up in the morning but is generally happy and walks around the home. The staff member said that this person knows their own mind and can be direct in making her views known and engages well with staff. The resident is also known to enjoy the sunshine and loves their sleep.

Discussion was held around their role, and they shared that they felt able to be flexible in their job and always found time to be able to sit and chat with the residents. The contract monitoring officer was told that Mondays were the busiest day, but they still engage meaningfully with the residents and get involved in activities.

If there is a quiet spell and there wasn’t a lot of stimulation, they said that they would either go for a walk in the garden or do some singing or dancing, play connect four or do some arts and crafts with the residents. They reported that they were encouraged to offer suggestions for improving the quality of life for those they support, and this is regularly discussed during team meetings and had input into the general running of the service. It was noted they didn’t have any issues at the time of the visit in the way the home operated and highlighted that there was ongoing work around the aesthetics of the property.

The staff member appeared confident in being able to challenge a colleague if they witnessed anything they felt was poor practice. It was reported that they would speak to the other person involved directly and would escalate to the home manager. They were aware that if they were concerned about the home that there were other avenues they could take to raise the matter externally or anonymously if they wanted.

There were no training needs identified and it was explained they were growing in confidence and there was more detail being provided around dementia.

Registered manager questions

The manager said they were responsible for two properties and the visits from the responsible individual are planned at the beginning of each year.

There is no CCTV at the property and the manager said there were no issues in relation to the property. It was explained that there are radiator covers in the bedrooms and the temperature is set by the thermostat. There are window restrictors in place if the residents want to have some fresh air. It was highlighted that there were no outstanding notifications to be made to Care Inspectorate Wales at the time of the visit.

Deprivation of liberty referrals were being monitored every month and there were none that were outstanding. There are reminders in the diary to prompt staff to renew these before they are due to expire. Residents and relatives are involved in activities, and they are informed verbally of any events and celebrations.

Community participation is mainly though going out for meals, coffee mornings, visit to the cinema, musical shows, shopping, holidays, and day trips. Although it was stated that the residents are not able to be actively involved in the recruitment of staff, they are introduced as part of the interview and their interaction is observed.

Resident questions

The two gentlemen that lived at the home were spoken to as part of the visit. It was reported that the lady had decided to remain in her room as she wasn’t feeling very well, although it was noted that she was supported to have a shower.

Due to communication difficulties, it wasn’t possible to get direct verbal feedback from the residents, however, it was observed that one was out walking around the garden with a member of staff and the other gentleman was smiling an appeared comfortable and relaxed and was happy to show his room to the contract monitoring officer. The other gentleman was smiling and appeared content in the activity room whilst the contract monitoring officer was talking to a staff member.

Corrective / Developmental Actions

Corrective actions (To be completed within 3 months of the date of this report)

The training for dementia care to be reflected on the matrix and training around communication to be sourced. RISCA version 2 (April 2019) regulation 36.

Agreed goals should be clearly recorded around weight loss to maximise independence. RISCA version 2 (April 2019) regulation 15.

Service providers identify an individual’s communication needs as part of their determination as to whether the service can meet their needs. RISCA version 2 (April 2019) regulation 24.

The spindles on the stairs to be replaced/fixed, the curtain rail in the bedroom seen to be replaced and the redecoration of the bathroom to be completed. One of the locks on the bedroom door downstairs to be replaced so that it can be easily opened in the event of an emergency. RISCA version 2 (April 2019) regulations 43 and 44.

Individuals are provided with keys to the home and their rooms unless their risk assessment indicates otherwise. RISCA version 2 (April 2019) regulations 43 and 44.

Developmental actions

The manager to contemplate booking relevant staff onto the International Certification of Digital Literacy.

The full names of all staff member to be shown on the supervision and appraisal matrix.

Where a birth certificate and/or passport isn’t available it is recommended that a file note is kept providing an explanation.

Where possible, interviews to be conducted by two senior members of staff.

Consideration to be given to adding a statement to the service user guide highlighting that it will be reviewed at least annually.


Victoria house was seen to be delivering a caring, supportive service to those living at the home. Staff were helpful and welcoming, and it was evident that they had a thorough understanding of the abilities and preferences of the residents. There was a lot of space to give residents the option of interacting with each other and staff or to have time alone without having to go to their room.

It was acknowledged there had been a change of manager since the previous visit and they appeared to have settled into their role and informed the contract monitoring officer that they intended to participate in a computer literacy course to assist them in their role.

There were no issues or concerns raised during the monitoring process and it was pleasing that two of the actions from the previous visit had been completed. The contract monitoring officer felt confident that the actions highlighted within this report can be completed within the three month guideline and that the manager will continue to make positive changes.

The contract monitoring officer would like to thank everyone involved in the process for their help, time, and hospitality. Unless deemed necessary to be moved forward, the next visit will be in approx. 12 months.

  • Author: Amelia Tyler
  • Designation: Contract monitoring officer
  • Date: 15th March 2024